FE4

Case Number:................................................................

I hereby declare that the employment grievance(s)/employment dispute(s) outlined below has/have not been resolved in mediation held on................................................................, and, in accordance with section 194(5) of the Act, I hereby refer the employment grievance(s)/ employment dispute(s) to the Employment Relations Tribunal.

Outline of unsettled employment grievance(s)/employment dispute(s):

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Name of Appointed Mediator

Signature of Appointed Mediator Date

Note:

• •Please attach corresponding Form ER1 or Form ER6
• •Additional information can be also attached
• •A copy of this Form and Form ER1 to be sent to the Permanent Secretary
• •A copy of this Form to be sent to the Mediation Services.